|Year : 2020 | Volume
| Issue : 2 | Page : 114-119
Periodontal health status and treatment needs of the community in Indonesia: A cross sectional study
Agus Susanto, Dyah N Carolina, Amaliya Amaliya, Indra M Setia Pribadi, Aldilla Miranda
Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
|Date of Submission||24-Jun-2019|
|Date of Acceptance||09-Oct-2019|
|Date of Web Publication||28-Mar-2020|
Dr. Agus Susanto
Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Sekeloa Selatan I, Bandung 40132.
Source of Support: None, Conflict of Interest: None
Aim: Periodontal disease is an oral disease with a quite high prevalence in the world, especially in the developing countries such as Indonesia. The aim of this study was to evaluate the prevalence of periodontal disease, periodontal health status, and treatment needs of the community in Indonesia. Materials and Methods: This is a descriptive study with cross-sectional approach. A total of 400 participants were selected for the proposed research work from six Community Health Centre (Puskesmas) in Bandung City. The demographic and sociodemographic data obtained from the questionnaire were recorded, including age, gender, address, occupation, and smoking habits. The oral hygiene level was measured by using the Oral Hygiene Index simplified (OHI-S) and the Community Periodontal Index of Treatment Needs (CPITN). Data were analyzed using chi-squared test and multiple linear regression analysis. Results: The oral hygiene level was found good in 16.5%, fair in 68%, and poor in 15.5% of all the samples; the oral hygiene level in male tends to be worse than women. The CPITN score of code 1 was found in 1%, code 2 in 54.25%, code 3 in 43.25%, and code 4 in 1.5% of all the samples. In total, 1% treatment needs required oral hygiene instruction, 97.5% oral hygiene instruction and oral scaling prophylaxis, and 1.5% complex treatment. The frequency of brushing teeth and age were significantly associated with OHI-S score (P< 0.05), whereas age and sex (male and female) were significantly associated with CPITN score (P < 0.05) in multivariate analysis. Conclusion: In the study population, the number of patients who had gingivitis was 55.25% and who had periodontitis was 44.75%. The majority of them needs the primary and secondary levels of preventive program to reduce the initiation or progression of periodontal diseases.
Keywords: Community Periodontal Index of Treatment Needs, Oral Hygiene Index Simplified, Oral Hygiene Status, Treatment Needs
|How to cite this article:|
Susanto A, Carolina DN, Amaliya A, Setia Pribadi IM, Miranda A. Periodontal health status and treatment needs of the community in Indonesia: A cross sectional study. J Int Oral Health 2020;12:114-9
|How to cite this URL:|
Susanto A, Carolina DN, Amaliya A, Setia Pribadi IM, Miranda A. Periodontal health status and treatment needs of the community in Indonesia: A cross sectional study. J Int Oral Health [serial online] 2020 [cited 2020 Jul 11];12:114-9. Available from: http://www.jioh.org/text.asp?2020/12/2/114/281482
| Introduction|| |
Periodontal disease is the most common oral disease in the world, especially in the developing countries such as Indonesia. Periodontal diseases are chronic infectious diseases that result in the inflammation of specialized tissues that surround and support the teeth. It can lead to a progressive loss of connective tissue attachment and alveolar bone. This tissue destruction is characterized by the formation of periodontal pockets. The high prevalence of periodontal disease is generally caused by a lack of individual awareness, a rare visit for oral health control, low socioeconomic status, and high levels of illiteracy. Periodontal disease are thought to be affecting individual general health problem as the risk factor for various systemic diseases such as cardiovascular disease, premature low-birth-weight babies, respiratory disease, and diabetes mellitus.
Although microorganisms present in dental plaque are the main etiologic factors responsible for initiation and progression of periodontal diseases, several other risk factors such as sociodemographic factors (age, sex, education, income, occupation), medical conditions (diabetes, cardiovascular disease (CVD), arthritis, kidney disease, respiratory disease, stress), and habitual factors (smoking, tobacco use, alcohol, oral hygiene practices) are also associated with periodontal disease.,
Preventive programs are needed to prevent periodontitis at the community level. This plan is based on information from the referral countries regarding determinant health distribution regulation. A national health survey on oral health in Indonesia has not been existing yet. Local research on the prevalence of periodontal diseases is also rare. CPITN (Community Periodontal Index of Treatment Needs) is an index to estimate the prevalence of periodontal disease and the treatment needs, and most often used in a research survey of periodontal disease in a community. Previous research on the prevalence of periodontal disease in Bandung City stated that the prevalence of 31% chronic periodontitis (CP) and aggressive periodontitis was 3.13%., Prevalence of CP in general adult population was reported to be 30–35%, with approximately 10–15% diagnosed with severe CP. In Malaysia, the prevalence of the CP and severe CP was reported as 48.5 and 18.2%, respectively. This study aimed to determine the prevalence of periodontal disease, and also periodontal health status and treatment needs in the community population in Bandung City, Indonesia.
| Materials and Methods|| |
This is a descriptive study with cross-sectional approach. The study was conducted from February to April 2016 in Bandung, a capital city of West Java. There were total 30 community health centers in Bandung City. A multistage stratified random sampling technique was used in selecting the community health center. Six health centers were chosen representing six development areas in the city of Bandung. The inclusion criteria of the study included the patients of aged 11–74 years, who had no history of periodontal therapy in the last six month, patients who were younger than 17 years gave consents by the parents or their representative. The exclusion criteria of the study included the patients with edentulous and acute oral disease. A written informed consents were taken from the participants before enrolling them into study. Sample size was calculated using single population proportion formula: n = p (1 – p) Z2 /d2 with an assumption of 95% confidence level (Z2 = 1.96), d = degree of precision desired (5%), and p = population proportion of oral hygiene status or periodontal health status. In this study p (1–p) was taken 0.25 (or P = 0.5). On the basis of the aforementioned formula, we need 384 subjects to ensure adequate sample size in light of anticipated responsive error. The estimated sample size was increased of 400 patients. All the examinations were carried out by trained dental practitioners, who examined each person seated on dental chair under adequate light. Intra-examiner reproducibility tested using Kappa index was 0.74. The demographic and sociodemographic data obtained from the questionnaire were recorded, including age, gender, address, occupation, medical records, oral hygiene habit, and smoking habit .
| Oral Hygiene Status|| |
Oral hygiene status was assessed by Simplified Oral Hygiene Index (OHI-S), which has two components: the Debris Index-Simplified (DI-S) and the Calculus Index-Simplified (CI-S), which are calculated separately and are summed up to get OHI-S for an individual., The examination was carried out using mouth mirror and explorer. The interpretation of index is as follows: good—0 to 1.2, fair—1.3 to 3.0, and poor—3.1 to 6.0.,
| Community Periodontal Index of Treatment Needs Index|| |
Periodontal index used was the CPITN by Ainamo et al. The teeth examined were 17, 16, 11, 26, 27, 37, 36, 31, 46, and 47. The examination was performed using the WHO probes or CPITN probes and mouth mirror with good lighting. Each tooth was checked for the pocket depth, detection of calculus, and bleeding response. Examination of each tooth was performed on the mesial, midfacial, distofacial, mesiolingual/palatal, midlingual/palatal, and distolingual/palatal parts. Before the study, all operators were calibrated regarding the CPITN score assessment.
The scoring code criteria were as follows:
0 = healthy;
1 = bleeding on probing;
2 = supra or subgingival calculus;
3 = there is a pocket with a depth of 4–5 mm;
4 = there is a pocket with a depth of more than 6 mm.
The subjects were diagnosed with CP if they have the scoring codes of 3 and 4. The categories of the treatment needs were as follows:,
0 = no treatment (code 0);
I = improvement in personal oral hygiene (code 1);
II = oral hygiene + scaling (codes 2 and 3);
III = oral hygiene + scaling + complex treatment (code 4).
| Statistical Analysis|| |
Statistical analysis was performed using the Statistical Package for the Social Sciences software version 20.0 (New York, USA), and the Shapiro–Wilk test was used to test data normality. All collected data were processed descriptively by presenting the size of the number and analytically by making a cross-tabulation between one variable and other variables. The significance value was calculated by the chi-squared test. Multiple linear regressions were used to estimate regression coefficients, standard errors, and 95% confidence intervals (CIs). A value of P < 0.05 was considered statistically significant.
| Results|| |
A total of 400 subjects were selected to participate in the study: 110 men and 290 women. The subjects were divided into the following age groups: <14 years old, 15–24 years old, 25–34 years old, 35–44 years old, 45–54 years old, 55–64 years old, and 65–74 years old [Table 1]. The highest number of subjects was found in the age group of 25–34 years old(128 people [32%]).
The oral hygiene level (OHI-S) included in the good category was found in 66 subjects (16.5%), fair in 272 subjects (68%), and poor in 62 subjects (15.5%) [Table 2]. On the basis of the gender, the oral hygiene level of males was good in 10.9%, fair in 70.9%, and poor in 18.2%; however in females, the oral hygiene level was good in 18.6%, fair in 66.9%, and poor in 14.5%.
[Table 3] shows the distribution of the subjects based on age groups according to the CPITN index criteria. Among all 400 subjects, 4 subjects had bleeding on probing, 217 had calculus around their teeth, 173 had a shallow pocket, and 6 had a deep pocket. The percentage of the shallow and deep pockets increases along with age, thus indicating that periodontal disease is associated with age. The percentage of CPITN index for the presence of calculus in men (60.9%) was found to be higher than women (51.7%). However, the shallow and deep pockets were found to be higher in women than men. The frequency of brushing teeth and age were significantly associated with OHI-S score (P< 0.05), whereas age and sex (male, female) were significantly associated with CPITN score (P< 0.05) in multivariate analysis [Table 4] and [Table 5]., ,
| Discussion|| |
Oral hygiene status as measured by the amount of supragingival plaque has been consistently shown by cross-sectional studies to have a significant effect on periodontal health., In this study, majority of the subjects had a fair level of oral hygiene (66%). This result was reflected by the good level of oral health knowledge; mostly brushed their teeth twice a day, although the level of dental visits was still rare. On the basis of the gender, the oral hygiene level of males was worse than females. This result may be reflected by the male’s lack of awareness regarding the importance of oral health as compared with female, and most male participants (72.7%) also had smoking habits.
Periodontal disease is an inflammatory disease of periodontal tissue caused by plaque bacteria. Several risk factors and indicators have been associated with the occurrence of destructive forms of periodontal diseases. There is much evidence that cigarette smoking and diabetes mellitus are important risk factors for clinical attachment loss. Other risk factors, including age, gender, race, socioeconomic status, and specific subgingival bacteria, are also associated with periodontal disease. Smoking habit is one of the risk factors with a large influence on the progression of periodontal disease. Cigarette smoking, nicotine, and its byproducts have a vasoconstrictive effect. They may be reducing the functionalactivity of leukocytes and macrophages in the saliva and crevicular fluid, as well as decreasing chemotaxis and phagocytosis of blood and tissue polymorphonuclear (PMN) leukocytes, thereby likely depressing phagocyte- mediated protective responses to periodontal pathogens, reducing the oxidation-reduction potentials (Eh) and increasing the proportion of anaerobic bacteria in dental plaque.
The results of this study showed that the prevalence and severity of periodontal disease increases with age. This is in line with previous studies which stated that the severity of periodontal disease increases because of the untreated cumulative effect of disease process over a period of time instead of aging process., The extent and severity of periodontal disease were shown to be different in different age groups and the general trend observed in the majority of the studies had increasing severity with age. The prevalence and severity of periodontitis increases with age, generally affecting both sexes equally. Periodontitis as an age-related disease, not age related. It is not the age of the individual that causes an increase in disease prevalence, but rather the length of time periodontal tissue that is challenged by chronic plaque accumulation.,
The results showed that the oral health status was based on the CPITN criteria. The number of patients who had gingivitis (codes 1 and 2) was 55.25%, and who had periodontitis (codes 3 and 4) was 44.75%. The CPITN index is a clinical parameter commonly used to assess the prevalence and status of oral health in epidemiological studies of periodontal disease. This index can be used on a survey in groups that are large, simple, and relatively easy to do, and having international uniformity for screening the population. According to the data taken from the third National Health and Nutrition Examination Survey (NHANES III), gingival bleeding was most prevalent in the 13–17-year-old group (63%) and declined gradually through the 35–44-year-old group. The extent of gingival bleeding was found higher in the younger and older group than in the middle age groups. This condition may be influenced by hormones during puberty and decreased organ function and disease in elderly.
The prevalence of periodontitis in this study was 44.75%. This result was higher than the study reported by Han et al., who stated that the prevalence of periodontitis in Asia was only around 32.3%. However, the prevalence of periodontitis in this study was almost the same as the research conducted by Jagedeesan et al. suggested that in Pondicherry the overall prevalence was 45%. Different results with previous studies were possible because of differences in the periodontitis parameters, subject population, rural and city location, and social status. All of which will affect the periodontal health status.
On the basis of the CPITN criteria, the highest percentage of study subjects who received the score of 2 (presence of calculus) in the 15–24-year-old age group was 70.4%. The shallow pocket was found in 85.7% of the 65–74-year-old age group, and deep pocket was found in 14.3% of the 65–74-year-old age group. The presence of calculus in male was found to be higher in percentage as compared with female, but the presence of deep pockets tends to be found more on the female subjects. The male subjects obtained a score of 2 (calculus) because of the male’s lack of awareness on maintaining the oral hygiene and their smoking habits. About 80% of male subjects in this study were smokers. Smoking may alter the neutrophil chemotaxis, phagocytosis, and oxidative burst. It can also increase the secretion of the tumor necrosis factor alpha, prostaglandin E2, neutrophil collagenase, and elastase in the gingival crevicular fluid.
The relationship between the level of oral hygiene (OHI-S) and the CPITN index had shown a positive relationship. It is possible that the oral hygiene level is associated with the severity of periodontal disease. In this study, most of the subjects had fair oral hygiene level and CPITN index of code 2. Oral hygiene was significantly associated with periodontal status using the CPITN index. Subjects with poor oral hygiene also had poor periodontal status. Poor oral hygiene leads to poor periodontal status through direct mechanisms such as high bacterial challenge to periodontal tissue, exotoxin, endotoxin, proteolytic, and hydrolytic enzymes release, and also toxic metabolic products; indirect mechanisms occurred through hypersensitivity reactions, activation of antigen and antibody reactions, and activation of complements. Individuals with poorer oral hygiene or higher plaque score were more likely to have more severe periodontal disease.
In this study, only 1.5% of all subjects needed complex care. Periodontal treatment needs in this study population were mostly oral hygiene instruction and oral prophylaxis, which were found in 97.5% of the subjects. This result indicated that majority of the research subject population required primary and secondary levels of preventive program to educate, motivate, and instruct people regarding the oral hygiene maintenance, and provide the treatment in its early stage to reduce the chances of initiation or progression of periodontal disease. Limitations of this study were heterogen subjects, and great variation in age groups. In addition, this cross-sectional study is limited to only six community health centers in Bandung. Therefore, the results of this study cannot be generalized to entire Bandung area. With regard to the indices used, CPITN does not evaluate the clinical attachment loss; hence, it cannot determine the criterion of the disease. To the best of author knowledge, this is first publication of CPITN study in Bandung City. A study by Savira et al. only examined study population in patients with diabetes mellitus.
| Conclusion|| |
Within the limitation of this study, it can be concluded that the number of patients who had gingivitis was 55.25% and who had periodontitis was 44.75% in the study population. The majority of them needs primary and secondary level of preventive program to reduce the initiation or progression of periodontal diseases. Age and sex (male, female) were significantly associated with CPITN score.
We thank all the respondents and staff of the Periodontology Department, the Faculty of Dentistry for the support of this study.
Ethical policy and institutional review board statement
The ethical approval of the research was obtained from Health Research Ethics Committee, Faculty of Medicine, Universitas Padjadjaran (Protocol no. 089/UN6.C1.3.2/KEPK/PN/2016).
Financial support and sponsorship
This research was funded by research grant from Universitas Padjadjaran.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]